Right track 15

1. On track machine risk
Time to think again?
righttrackIssue 15 Spring 2016
Our regular features:
RAIB REPORT BRIEF
Near miss Hest Bank
The Lowdown
Rachel Poynter, station
manager
SPADtalk
Second look at Tangmere
Newswire
Proceeding at caution Reducing risk at the PTI Yellow front ends

2. Headlamp
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It’s easy to assume that safety at the platform edge is pretty much
down to how the passenger behaves. And while this is a big factor,
is there anything that staff can do to reduce the risks there? We
find out about a new initiative designed to answer that question.
Trackside, one company tells us how they reconsidered the safety
around on track machines. We also look at a new guidance note
on proceeding at caution, and the possible impact of changes in
standards on yellow front ends.
As always, we have our regular features, including Newswire,
SPADtalk, and our RAIB report, which looks into the close call at
Hest Bank. And in the Lowdown we look at what a major station’s
renovation offers by way of smarter safety.
As ever, we would love to hear your views about Right Track. If
you have any comments on this issue’s articles, or suggestions for
future stories, please get in touch via righttrack@rssb.co.uk.
Welcome to the Spring 2016
issue of Right Track.
Right Track can be downloaded from Opsweb -www.opsweb.co.uk.
Right Track is produced by RSSB through cross-industry cooperation. It is designed for the people on the operational front-line on the national
mainline railway, yards depots and sidings and London Underground.
Their companies are represented on various cross-industry groups, including the System Safety Risk Group, managed through RSSB, and Right
Track is overseen by a cross industry editorial group.
RSSB The Helicon 1 South Place London EC2M 2RB Tel: 020 3142 5300 email: righttrack@rssb.co.uk web www:rssb.co.uk www:opsweb.co.uk
Printed by Urban Juice / Willsons Group Services.
Right Track is designed to share news and views from individual companies in a positive way. However, the views expressed in Right Track are
those of the contributing authors; they do not necessarily reflect those of the companies to which they are affiliated or employed, the editors of
this magazine, the magazine’s sponsors - the System Safety Risk Group - or the magazine’s producers, RSSB (Rail Safety and Standards Board).
Contents
03 The Lowdown
04/7 On track machine risk
08/9 Reducing risk at PTI
10/11 Proceeding at caution
12/13 And it was all yellow
14/15 RAIB Report Brief
16 SPADtalk

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Rachel joined the rail industry ten
years ago, working in customer
services for Trans Pennine Express.
She moved on to become duty
station manager until October
2014 when, looking for a new
challenge, she joined Northern to
take Manchester Victoria through its
redevelopment.
“When I started two years ago, Man
Vic was drab and dark; it didn’t feel
safe or welcoming and the roof
was always leaking” Rachel tells
me (an IRA bomb in 1996 caused
extensive damage to the station
and city’s infrastructure and injured
212 people). Since then, the station
has seen a £45million refurbishment
programme.
It now has a new curved
roof, made of ETFE (ethylene
tetrafluoroethylene – the same
stuff as used in the Eden project in
Cornwall), a bright concourse, and
a fully accessible walkway leading
directly to Manchester Arena. Many
of the heritage features of the old
station were given some much
needed TLC to bring back their
former glory: the mosaics have been
redone, as has the glass dome over
what is now a beer and burger joint.
The result is a bright concourse
behind a heritage building, bringing
together the history and future
of rail.
The station runs 24/7, with a total
of 47 station employees and more
than 400 drivers and conductors.
“Our focus has always been on
making the station safe and
welcoming,” says Rachel.
This includes everything from
extra crowd management when
a charter train makes a stop, to
building relationships with the local
community. Rachel confides that
sometimes pleasing everyone is not
easy. Yet the team at Victoria seem
to be doing a good job. When I
visited, there were stars stuck to the
floor of the concourse, celebrating
Northern’s North of England award
for customer service.
So what next for the station? Well,
the new Northern franchise started
on 1 April 2016. Rachel hopes that
this will lead to extra funding, to
make the station even better for its
employees and customers.
The Lowdown
Manchester Victoria, named after the Queen at the time, opened in 1844. Today is
one of the largest stations in the north of England, welcoming 10 million passengers
a year and up to 300 trains each day. The listed building has recently undergone a
refurbishment programme. So, what does it take to run a station that big? Station
Manager Rachel Poynter of Northern talks to RSSB’s Martha Parkhurst.

4. On Track Machine Risk
Time to Think Again?
Managing risk is a legal requirement: the law requires
all companies to examine all the tasks they do, and
to think carefully about the risks. But it is as much about
ensuring employees are safe at work, and fundamental
to any strategy which aims to reduce staff injuries in a
quest to achieve Zero Harm.
The rail industry provides many hazards to staff, so it is
essential we do not overlook the basics. Across Balfour
Beatty Rail, we have taken a fresh approach to ensuring
the safety of our workforce, which brings management
and front line employees together as one to consider and
take action on risk.
Changing Expectations
Many on-track machines (OTMs) in use were
manufactured long before some of today’s stringent
regulations came into force (and at a time when
standards in general were less onerous). But like many
other industries, our tolerance of risk has changed, and
our expectations have vastly increased when it comes
to acceptable controls in new tools, equipment and rail
vehicles. So what can we do about the older ones?
One of the most important aspects of health and safety management is the effective
identification and reduction of risk. Balfour Beatty Rail Plant’s Health and Safety Business
Partner, Darren Kitchener, explains how it has been re-thinking risk evaluation across its fleet
of on track machines.
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The Problem
With heavy machinery comes significant risk and if these
risks are not adequately controlled, they can lead to
serious injuries. Tamping machines, for example, have
bulky, fast moving and powerful components designed to
lift and pack track. These components pose an obvious
risk to those people working close to an operating
machine but also to the staff servicing and repairing this
equipment. So risk assessments must be carried out for
the operators, track workers and fitters.
The trouble is risk assessments can often be ‘generic’,
with poorly defined control measures. This means the
level of control isn’t always proportionate to the risk
present. Often, we go through the motions of producing
an assessment because it has to be done, but don’t
always use the outputs to change what we do. There are
many examples where these types of risks are present,
but all too often, not enough is done to prevent exposure.
Risk assessments often fail to use the hierarchy of
controls. Relying on warning signs or introducing a
procedure to prevent access to moving parts for example,
relies entirely on people to do the right thing, whereas
fitting a guard around a moving part removes the risk
altogether. The Provision and Use of Work Equipment
Regulations place a duty on employers to ‘think about
how a machine can be made safe’ and the measures
used to prevent access must be considered in a specific
order (this is the hierarchy of control):
• Use fixed guards to enclose the dangerous parts,
whenever practicable.
• If fixed guards are not practicable, use other methods
(eg interlocking so the machine cannot start if the
guard isn’t in place).
• Where guards cannot give full protection, use jigs,
holders etc if it is practicable.
• Control any remaining risk by providing the operator
with the necessary information, instruction, training,
supervision and appropriate safety equipment.
Avoiding Complacency
We often accept our workplace for what it is, and
don’t always see the everyday risk or we put up with
things that are not right and develop a ‘work around’.
Sometimes you should step back to see the risks that
were previously been accepted. I spent time with some
of the crews and fitters, and by taking them away from
the normality and routine, we started to see everyday
hazards. During one assessment of a tamper, the
operator was able to highlight a number of potential
issues that existing assessments had simply not picked
up on, but had long been accepted practice, and we were
quickly able to identify improvements.

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The Golden Questions
Our new approach has been established to focus the
mind by asking specific questions designed to tease out
potential hazards and problem areas. Gone are the A4
style assessments with the 5 x 5 risk ratings, and the
many pages of text with generic statements.
Instead, our approach requires the operators who
actually use the equipment to walk around the machine,
answering 18 risk questions, pointing out the specific
hazard, before we pop the vital question ‘Can the current
controls be improved?’
“As an operator, getting involved with the risk
assessment process to this level of detail has
really made me think differently about things”
Fall from height - Are there un-guarded areas where
there is a risk from falling?
Entanglement - Are there any rotating drive shafts
present?
Draw-in entrapment - Are there any exposed belt and
pulley/chain or sprocket drives?
Impact - Are there any machine accessories or parts that
could strike against people or vehicle?
Ejection, stab or puncture - Are there any parts where
debris could be ejected?
Unexpected start up - Are there any systems that could
unexpectedly be started by others?
Loss of stability - Are there any parts that could fall
through loss of stability or detachment?
Crushing - Are there risks from falling or moving parts
that could result in a crushing injury?
Sheering - Are there any moving parts close to other
parts that could cause cutting or severing?
Break–up during operation - Are there any parts that
could fail due to wear, tear and strain?
Unexpected overrun - Could any parts continue to move
– even when powered down?
Stored energy - Is there any part where stored pressure is
present (for example electrical or kinetic)?
Cutting or severing - Are there significant sharp or
jagged components present?
Injection - Is there risk of hydraulic fluid being injected as
a result of a failed component?
Errors of fitting - Are there any risks from wrongly fitted
attachments or components?
Electric shock - Are there any high voltages present that
could result in an electric shock?
Fire - Are there any sources of fuel, ignition or heat that
could cause a fire?
Slips, trips - Are there any significant risks present that
could result in a slip or trip injury?
We found that the exercise was highlighting common
themes across all the machines reviewed, so we published
the ‘top risks’ to share them across the business.
Newswire
10 December 2015, US: Boston
runaway driver put on ‘admin leave’
Just after 06:00 (local time), a commuter train left
Braintree without a driver. It passed four stations
before officials cut the power to the third rail. There
were no reported injuries. Reports reveal that the
driver had tied a cord round the train’s power handle
and had not secured the brakes when leaving
the cab for a ‘signal issue’. He has been put on
‘administrative leave’.
22 December 2015, Mexico: Level
crossing collision kills 4 near Mazatlán
A bus was struck by a train on an open level crossing
in Mazatlán, Mexico, killing four people (including
the driver) and injuring 22 more. The bus crossed
the line moments after a car had successfully done
so. Police believe this lulled the bus driver into
thinking it was safe to follow.
27 December 2015, Australia: Freight
carrying sulphuric acid derails in
Queensland
At 10:20 (local time), a freight carrying around
800,000 litres of sulphuric acid derailed near Julia
Creek, Queensland. The locomotive and all 26
wagons left the rails; the three crew members
sustained minor injuries.

7. Good Safety is Good Business
Making the improvements to reduce risks in older plant
can be difficult and expensive, particularly where retrofit
components have to be designed and added to earlier
equipment. However, it’s widely accepted that good
safety is good business; so when updating some of
the components (like fitting replacement engines, or
repainting the external livery), why not invest in installing
additional guarding and improved access lighting, or
apply non-slip paint to the external surfaces?
What’s in it for the Industry?
The industry is striving for ever-improving safety
performance and Zero Harm. So what does this mean for
you? Eliminating risk will obviously reduce the number of
injuries; but these material safety measures are not the
only way we’ll reach our goal of ‘everyone home safe,
every day’. We need help from our people too.
Since we started re-examining risk, we have already seen
evidence of a changing culture. A greater awareness of
risk has led to an increased appetite for the reporting of
close calls. And as the number of close calls increases, so
the number of injuries decreases, and the safety of all our
staff improves.
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Moving Parts – Risk of entrapment, crushing
or entanglement from unguarded rotating or
moving parts.
Falling whilst accessing cabs – Risk of falling
from the machine whilst gaining access.
Some cabs have limited guarding, non-aligned
steps or poorly located handrails.
Unexpected start-up – Risk of any part of
the machine being started by others without
warning when working on components such as
motorised or electrical parts.
Access to high level components – Risk when
required to access some areas of the machine
where access platforms may not be available.
Pressurised hydraulics – Risk of hose failure and
contact with pressurised hydraulic oil when
working near, or leaning against, pressurised
hoses.
Contaminated checker plate – Risk of slipping
where checker plate is wet, icy or contaminated
with oil.
The Top Six Risks in Plant
4 January 2016, US: Level crossing
collision injures 22 at Lake Worth
Just before 07:00 (local time), a passenger train
struck a dustbin lorry which had broken down on
a level crossing at Lake Worth station, Florida. 22
passengers were injured; all were taken to
hospital for treatment.
8 January 2016, Thailand: Crossing
collision at Phetchaburi kills 3; injures 34
At 10:35 (local time), a passenger train struck a cattle
lorry on a level crossing at Phetchaburi station. The
lorry driver, his passenger and one rail passenger were
killed; 34 people were injured. The heavily laden lorry
was reported to have been speeding as it approached
the interface. It then crashed through the lowered
barriers and into the side of the train.
12 January 2016, Philippines: ‘Jeepney’
driver charged after 1 killed in crossing
collision
At around 19:00 (local time), a passenger train struck
a ‘jeepney’ on a level crossing in Paco, Manila. One
road vehicle passenger was killed and six more were
injured. The ‘jeepney’ driver was later charged with
dangerous driving.

8. Newswire
Reducing risk at the PTI
Accidents on the platform are the biggest fatality
risk for passengers on the railway: in the last five
years, 19 people have been killed and over 7,000 injured
around the edge of station platforms. These accidents
can happen when getting on or off a train, or even when
there is no train stopped at the platform.
There have been high profile incidents at the platform
train interface (PTI), such as the trap and drags at West
Wickham, and Hayes and Harlington; a person who fell
off the platform at Sittingbourne and came into contact
with the third rail and a fall between the train and the
platform at Hamilton Square.
These incidents, added to the increasing pressures on
the network to increase capacity, performance and
accessibility, has led to a cross-industry response to the
problem. We need to improve co-ordination across the
industry, making sure that any new methods to control
the risk at the PTI are effective.
A cross-industry strategy to reduce injuries at the PTI was
published in early 2015. (It can be found on http://www.
rssb.co.uk/improving-industry-performance/platform-
train-interface).
Of course, passengers need to take some responsibility
for their safety; and in order to remind them of this,
stations across the network put up “lend a helping hand”
posters at Christmas last year. This reminded passengers
to take extra care in stations, and encouraged people to
reach out and help if they saw someone at risk. There is
also a booklet for staff working in trains and on stations
(see box on next page).
Stations come with different track layouts, platform
arrangements and service frequency. Some are on on
straight, others on curved track. Ideally, calculating the
risk at the platform edge needs to be done on a case by
case basis.
8 righttrack
To find out more,
visit www.lendahelpinghand.co.uk
To find out more,
visit www.lendahelpinghand.co.uk
To find out more,
visit www.lendahelpinghand.co.uk
14 January 2016, France: Level crossing
collision near Beuville; loco driver injured
At 04:05 (local time), a lorry was struck by an empty
freight at a level crossing between Beuveille and
Arrancy-sur-Crusne. The locomotive and 21 wagons
derailed. The track was damaged, the lorry was
dragged some 100 metres and the train driver
suffered minor injuries. The lorry driver – who just
managed to jump clear – suffered shock/trauma.
20 January 2016, US: Freight carrying
sulphuric acid derails in California
At around 08:00 (local time), three wagons carrying
sulphuric acid derailed In Martinez, California. There
were no reported leaks or injuries. The cause of the
incident has yet to be determined.
28 January 2016, US: Passenger train
derails at Pompano Beach, Florida; 1
passenger injured
A Tri-Rail passenger service derailed in Pompano
Beach, Florida. Of the 40 passengers on board, one
was injured. Some diesel fuel was also spilled, though
this was later contained. Reports suggest that the
locomotive struck debris before leaving the track.

9. A tool, which provides a common method to complete
PTI risk assessments at stations, will help to ensure
station managers and safety managers follow best
practice. The risk assessment tool provides a review
of the safety arrangements in place for managing
PTI risk at a station, and considers how effective
these arrangements are. It helps prioritise which
areas need improvement.
To ensure we continue to reduce risk at the PTI in an
ever-expanding and evolving railway, the industry will
continue with research, analysis, engagement and
sharing good practice. The outcomes will focus on
improving PTI data; influencing passenger movement
at the PTI; optimising methods of stopping and
dispatching trains; optimising the step and gap between
the platform and trains; and improving accessibility,
performance and capacity.
For 2016, the focus will be on reducing incidents around
trap and drag, alcohol consumption, and improving
competence management. The industry will continue
to work together to reduce the risk and improve
operational performance, capacity and availability of
access. This will benefit the mainline railway, including
all who use and work on it.
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“People in a safety critical role have an
obvious part to play, but accidents at
the platform edge can be the result of
actions, behaviours and decisions taken
by passengers long before reaching the
platform edge. Staff at the ticket office,
within the station or at the gate line
can really help to influence passenger
behaviour and potentially reduce the
occurrence of these incidents.”
Mark Philips, Director of Research and
Standards at RSSB
PTI guidance can be found in
the “Lend a helping hand” staff
booklet. This tells you in more
detail who is most at risk, and
what you can do to help prevent
an accident at the PTI, whatever
your role is on the railway. This
can be found on
http://www.opsweb.co.uk/
platform-train-interface-pti/
materials
31 January 2016, Egypt: Level crossing
collision near Cairo kills 7; keeper
blamed
At 07:30 (local time), seven people were killed and
three injured when a passenger service struck a
lorry at a level crossing in Giza, near Cairo. Initial
investigations imply that the crossing keeper ‘forgot’
about the train.
4 February 2016, Northern Ireland:
Passenger train strikes equipment on
line near Lisburn
At around 06:45, a passenger train struck ‘construction
excavation equipment’ on the line near Lisburn.
There were no reported injuries, but the incident
did cause widespread disruption to traffic.
5 February 2016, India: Passenger train
derails near Pachur; ‘broken rail’ cited
as cause
At 04:10 (local time), a passenger train derailed on
Vetapattu Bridge, between Somanaickanpatti and
Pachur. 14 passengers were injured. A broken rail
has been cited as the cause.

10. Proceeding at caution
Every year trains still strike objects on the line such as
trees, animals, vehicles and equipment, despite having
been instructed to proceed at caution.
Sometimes, part of the problem is that the people
involved in safety critical communication fail to come
to a clear understanding because of the way they
communicate.
So what does the Rule Book say?
You can find this in Rule Book Module TW1 Preparation
and movement of trains, Section 25.
To drive in the way described in the Rule Book means
you must take account of factors that could impact your
ability to see the hazard and stop the train. This could be
things like the weather: fog and mist will affect visibility.
If you’re driving on a curve, there may be something just
around the corner. How long and heavy is your train?
Are you on a downward gradient? How would these
factors affect your ability to stop the train?
You also need to stay on top of all driving tasks. What
about vegetation and line contamination?
And if you’re dealing with a moving hazard like an
animal or a trespasser, they may have moved since they
were last spotted. If that’s the case, you shouldn’t make
assumptions about where the hazard is. Anticipate it
to be just around every bend. And remember, you still
need to look out for and obey signals while proceeding
at caution.
Rule Book reminder
‘If instructed to proceed at caution, you must, as well as
not exceeding any specified speed, proceed at a speed
which takes account of conditions (such as the distance
you can see to be clear), that will allow you to stop the
train short of any train, vehicle or other obstruction, or
the end of your movement authority.’
How should you communicate the instruction to proceed at
caution; and how, as a driver, should you drive once the
instruction has been given?
Newswire
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6 February 2016, Australia: Commuter
train derails at Rushall, possible wheel
issue
At around 16:50 (local time), a commuter service
derailed at Rushall station, on Melbourne’s South
Morang line. One passenger sustained a minor
injury. The cause has yet to be determined, though
initial reports suggest a wheel-related issue.
9 February 2016, Germany: Collision
at Bad Aibling kills 11,
At 06:48 (local time), two passenger services
collided on the single line between Bad Aibling and
Kolbermoor. 11 people were killed (including both
drivers). The signaller allowed both trains on to the
single line in error. For more information, see RSSB’s
summary on Opsweb.
11 February 2016, Egypt: Over 70
injured in Beni Suef derailment
At least 73 people were injured when a passenger
train derailed and two of its carriages overturned
in Beni Suef. The incident occurred when the
locomotive struck a block of cement on the line.
The driver has been held responsible for the accident
since he did not follow the signaller’s instructions,
according to a spokesman for the operator.

11. This may all sound very…well…cautious. But this of
course is the point. The situations where drivers strike
objects will often be because they’ve opted to drive
too fast.
So how can you make sure the instruction to proceed is
clearly communicated and understood?
The people responsible for communicating this message
can be drivers, signallers, PICOPs, engineering supervisors
and safe work leaders.
Before authorising a driver to proceed at caution, the
driver must be given the information about the potential
hazard ahead (see box). You can give this information
via the GSM-R system, using a berth-triggered broadcast
where the driver gives a ‘non-verbal’ acknowledgement.
You can also have a two-way conversation over
the handset.
When giving the instruction to proceed at caution,
keep the conversation accurate, brief and clear.
Both parties should be identified straightaway. The
information should be repeated back at each key
instruction to confirm understanding. If anything is
unclear, seek clarification.
For more detail, see Rule Book Module G1 General safety
responsibilities and personal track safety for non-track
workers. Section 5 and Handbook 1 General duties and
track safety for track workers Section 9.
Proceeding at caution has been covered in two recent
editions of RED: RED 40 ‘Driving at caution’ – raises the
question of what proceeding at caution really means,
and advises on the correct way to contact a driver on the
move. RED 44 ‘Assuming safety’ - highlights the need
for clear communications and when there is a hazard
on the line.
Information to share with the driver before giving
the authorisation to proceed at caution:
• What the hazard is
• Where the hazard is – you must use major,
recognisable features of the line such as
tunnels, bridges, stations, signals and level
crossings
• Whether the hazard is moving and when the
hazard was last seen
• The section of line over which the driver is to
drive at caution
• Whether the driver is required to report back
with an update on the hazard
A new short guidance note on Proceeding at
Caution has been put together by operations
experts from across the industry (working through
the Train Operations Risk Group).
You will find this guidance useful if you are a
driver, signaller, engineering supervisor, or safe
work leader; or are involved in, or affected by, train
movements.
The new note is available on Opsweb –
www.opsweb.co.uk
Accurate
Brief
Clear
Identify
Repeat
Repeat
Repeat
Seek
clarification
righttrack 11
15 February 2016, US: Passenger killed
in ‘trap and drag’ on New York subway
At around 06:45 (local time), a commuter was
trapped in the doors of a subway train and dragged
to his death at Union Turnpike-Kew Gardens station.
A spokesman for operator MTA said that the
passenger had tried to board while the doors
were closing.
18 February 2016, Belgium: ECS runs
away; stopped by driver jumping on board
At around 21:00 (local time), an ECS formation ran
away from Landen station after its driver left the cab
to investigate an engine fault. It travelled for 7½ miles
before another driver jumped aboard and brought it to
a stand. SNCB is investigating.
19 February 2016, France: Eurostar
hits concrete blocks near Beloeil
On 19 February 2016, a Eurostar service heading
from St Pancras to Brussels hit a concrete block on
the line near Beloeil. The train was running at its top
speed, but did not derail. There were no reported
injuries. Initial investigations suggest the block to
have been placed deliberately, nearby fences having
been cut open to allow access to the track. Four
people are being questioned by police.

12. Newswire
23 February 2016, Netherlands: Train
collides with crane; driver killed
At 08:50 (local time), a passenger train derailed
after striking a mobile elevated work platform
(MEWP) on Lage Veld level crossing near Dalfsen.
The train driver was killed; seven people were injured.
Eyewitnesses told the Dutch media that the MEWP
had waited for one train to pass, but was struck by
a second while attempting to cross the line.
And it was all yellow
Companies are now able to make their own informed choice about
their trains’ front end colour, as long as the right risk assessment is
done and all affected parties are involved.
People out on the track or using level crossings need
to be able to see and hear trains so they’re able to
stay safe. Traditionally, train fronts have carried a yellow
panel in order to make them more visible.
It all started in the 1950s, when diesel and electric-
powered trains were gradually introduced on Britain’s
railways to replace steam locomotives. Being far quieter,
people working on or near the line found it more difficult
to anticipate when a new train was approaching, and
so the eye-catching yellow front began to appear on
a number of locos from 1962. Later builds wore the
panels from new, while up until privatisation, the BR
Corporate Identity Plan of 1965 made the canary-like
hue mandatory over a wider area.
However since that time, headlamp technology has
improved, and that meant that the standards about train
visibility needed to be updated. These updates came
into effect in March; and it’s now up to the companies
owning and operating trains to make sure they are
sufficiently visible. For new and modified trains, this
includes having the right arrangement of head lamps in
line with legal requirements; but the operator has more
flexibility about the colour at the front. Yellow is still an
option, it’s just the operator’s choice rather than a one-
size-fits-all tick box in a standard.
So what about safety out on the track?
As before, it is still your employer’s responsibility to
ensure compliance with health and safety at work
legislation, including managing risks and setting up
safe systems of work that adequately protect people
who need to go out on the track. And in the short term,
it’s unlikely you’ll notice any change to train fronts, not
least because existing trains may not have the right
arrangement of head lamps, and there’s a lot to consider
if a change is being thought about.
If an operator wants to introduce a train without a yellow
front end, they will need to consult all affected parties –
12 righttrack
7 March 2016, US: ‘Altamont Express’
derails after striking tree near Sunol
At around 07:45 (local time), a passenger train –
the ‘Altamont Corridor Express’ – was derailed when
it struck a fallen tree in Niles Canyon, near Sunol,
California. The leading carriage plunged into the
nearby Alameda Creek. The second vehicle derailed,
but remained upright. Fourteen people were injured,
four of them seriously.
3 April 2016, US: Passenger train collision
with digger kills two near Chester
At around 07:50 (local time), am Amtrak passenger
train derailed after striking a mechanical digger in
Chester, Pennsylvania, at between 50 and 60 mph.
Two maintenance workers were killed. The local senator
told the press that it was unclear whether the digger
was performing regular maintenance or whether it
was clearing debris from high overnight winds.

13. including your employer and trade unions. They need to
carry out appropriate risk assessments, including possibly
applying other EU requirements to manage the change
effectively, some of which is required in law if the change
is considered significant.
A range of factors needs to be considered, including
all operating conditions likely to be experienced by the
train, and the impact on the safety of railway workers,
passengers, members of the public and level crossing
users. Operators need to think about situations like
permissive moves into platforms where there is a train
already there – would the front end colour make a
difference on the perceived position? They also need
to avoid colours associated with signal aspects or with
high visibility clothing to avoid confusion. Reliability and
maintenance of the head lamps will also be critical.
In summary:
New or upgraded trains introduced to the network must
comply with legal requirements to have the correct
arrangement and illumination of head lamps. They can
also display a yellow front-end.
Indeed, the yellow front end is still a must for trains
without the new arrangement of headlamps, and the
spec for the yellow panel is still provided in the new
standard where companies find this to be good practice.
Yellow plant still has to be yellow all over, and shunting
locomotives and snowploughs still require forward-facing
surfaces to be painted yellow with black diagonal stripes
where it’s reasonable to do so.
righttrack 13
Further information
To find out more, talk to your line manager or appropriate safety contact in your organisation. Or contact us by email
enquirydesk@rssb.co.uk or telephone 020 3142 5400 if you have any questions.
Cows have broken through a fence and found their way onto the line.
How should you respond?
What happens when the rules aren’t followed?
We see how poor communications between driver and signaller,
and a failure to follow correct emergency procedures, allow the
situation to escalate into a serious incident.
RED 44
Also in RED 44:
• 175 years of the railway inspectorate
• How human factors affect SPADs
• Briefing drivers on routes undergoing significant change

14. 14 righttrack
It was the afternoon of Monday 22 September 2014,
and a group of nine track workers were repairing
a section of the West Coast Main Line south of Hest
Bank crossing, near Lancaster. The gang were on an
underbridge located on a curve, which made it hard to
see approaching trains. To reduce the risk, their safe
system of work involved a lookout operated warning
system (LOWS), supervised by LOWS controllers, and
designed to give a visual and audible warning at least
25 seconds before a train came near. This would give
the gang enough time to clear the track and move to
a designated position of safety, which was just off the
bridge and next to the Up line.
Warnings were being triggered by lookouts positioned
north and south of the site using transmitters.
The equipment had been working normally since the
start of the shift, but just before half-two a passenger
train came seemingly out of nowhere and powered
past the gang at close to 100 mph. Luckily, they saw
it just in time to get clear. They were understandably
shaken, but no physical injuries were reported.
Why hadn’t they had a warning? RAIB concluded that
there were two possibilities: either the lookout operated
the wrong switch on his radio transmitter by mistake,
or he forgot about the need to send a warning during
an intended delay period between seeing the train and
operating the warning switches.
RAIB report brief:
Near miss near Hest Bank

15. righttrack 15
The delay was down to the fact that he was positioned
on a long section of straight track and could see
approaching trains for significantly longer than the time
needed for the gang to get out of the way.
RAIB also noted that the lookout’s vigilance had
probably dropped as he’d been working continuously for
almost two hours.
Since the incident, Network Rail has tested LOWS
equipment that gives better user feedback, and
features a (more reliable) movement sensor instead of
a ‘vigilance switch’. The company also introduced ‘non-
technical skills’ training for lookouts. The programme
includes modules on attention management, which
cover the ability to remain alert and focussed, the
ability to manage distractions, and the ability to keep
an awareness of the overall situation.
The train operator – First Trans-Pennine Express –
re-briefed staff on its policy for capturing OTDR data
following reported incidents, as the relevant download
had not been made within 8 hours. This made the
investigator’s job harder than it needed to be, forcing
him to wade through several days’ footage before the
relevant section was found.
RAIB also recommended that Network Rail reassess the
working time limits and duration of breaks applicable
to lookouts, updating its guidance and instructions
accordingly. Network Rail will also re-consider the
circumstances in which LOWS should be used, in order to
try to reduce the chance of a single point of failure due
to the complete reliance on the action of one lookout.
Download of FFCCTV, courtesy of First TransPennine

16. The Railway Magazine’s Nick Piggott likened it to
Quintinshill, Britain’s worst railway accident. It sounds
melodramatic, but of course he was right: had the
timings been slightly different, a collision could have
occurred that would almost certainly have resulted in
death at levels not seen in this country for decades.
As it was, on the afternoon of 7 March 2015, there was
a SPAD, with no. 34067 Tangmere passing the signal
protecting Wootton Bassett Junction, before blocking it
soon after an HST had passed on clear signals. RAIB is
investigating this incident, and its findings are eagerly
awaited by all who operate steam, love steam, work with
steam – and run trains alongside it on the network.
So far, we know that the driver didn’t cancel the warnings
from the AWS, so the brakes came on. The trouble was,
he chose not to contact the signaller and report what
had happened, but cancelled the AWS using an isolation
cock on the locomotive. He also deactivated the TPWS.
He then opened the regulator and had built up such
speed that, when the locomotive activated the AWS for
SN43 signal – which was at caution – he couldn’t bring
the train to a stand at SN45, which was at danger.
The casual observer might look at this situation and
put the blame on the crew: something was done in the
cab that shouldn’t have been. The casual observer
would be right – but only up to a point. Errors seldom
occur in a vacuum, and this case has highlighted many
management failings beneath the seemingly obvious
surface. Indeed, RAIB has noted that the Wootton
Bassett SPAD wasn’t the only occasion on which
Tangmere‘s isolation cock was used by crew in order
to by-pass an AWS brake demand. ‘The extent of this
practice,’ says RAIB, ‘continues to be the subject of
further investigation.’
In some respects, the investigator’s march was stolen
when the regulator, the ORR, issued a Prohibition Notice
(PN) in February to the operator, West Coast Railway
Company Ltd (WCRC), banning it from running heritage
services on the main line. The ORR lifted the PN on
23 March 2016, having received evidence that clearer
governance structures – with proper accountability
for safety – had been introduced, along with more
robust risk assessments and enhanced staff
management processes.
The ORR Director of Railway Safety and HM Chief
Inspector of Railways, Ian Prosser, said he was
‘satisfied that WCRC has...taken all the necessary steps
to address the issues of concern on safety’, adding that
the regulator will continue ‘to closely monitor WCRC
over the coming period to ensure that their approach
is embedded into the culture of the company and that
they fully comply with all the commitments they
have made.’
RAIB’s report on the incident is now available on its
website. We’ll take a closer look in the next Right Track.
Right Track re-visits last year’s steam-hauled SPAD in Wiltshire
CCL Hec Tate CCL James F Clay
16 righttrack
SPADtalk
email righttrack@rssb.co.ukrighttrack